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Systemic and Tumor Directed Therapy for Oligometastic Prostate Cancer
Purpose: Metastatic prostate cancer is incurable and a standard treatment is life-long, palliative, hormone therapy. Improving treatments for Veterans with metastatic prostate cancer is therefore an unmet need.
Background: The approach to metastatic prostate cancer is evolving in response to improvements in androgen suppressive therapies, demonstration that stereotactic body radiotherapy (SBRT) offers control of metastatic sites in excess of 95%, and improved imaging. Retrospective data from the West LA VA suggests Veterans with metastatic prostate cancer with 5 or fewer metastasis have improved outcomes as compared to those with > 5 metastases. This raises the question if a multimodal approach with aggressive, early treatment of newly diagnosed metastatic prostate cancer could be attempted with curative intent.
Methods: We will conduct a single arm phase 2 trial in 28 Veterans with newly diagnosed M1a,b prostate cancer and 1 to 5 radiographically visible metastases staged by NaF or PSMA PET-CT. Treatments include radical prostatectomy and adjuvant fractionated radiotherapy, metastasis directed SBRT, and complete ADT: leuprolide, abiraterone acetate, apalutamide for a total of six months systemic therapy. The primary endpoint is the percent of Veterans achieving a PSA < 0.05 ng/mL six months after recovery of testosterone to ≥ 150 ng/dL, a surrogate for disease control. Secondary endpoints include biochemical progression, radiographic progression, cancer specific survival, health-related quality of life. Prior to treatment, Veterans undergo a radiographic directed biopsy of a metastatic lesion to confirm metastatic disease and obtain metastatic tumor tissue for correlative genomic studies. Genomic analyses to investigate molecular correlates to lethal primary prostate tumors and the emergence of metastases will use the pretreatment tissue from directed biopsies of metastases and the radical prostatectomy specimens.
Conclusions: Accrual will proceed over five years at the VA West LA and Long Beach Medical Centers. It is anticipated that determination of the primary endpoint for each patient will take place within 18 months of his initiation of therapy.
Implications: The treatment approach to Veterans with oligometastatic prostate cancer could pivot from palliation toward cure. The correlative analyses could identify genomic features of potentially lethal primary tumors and may elucidate the proximal mechanistic drivers of metastasis.
Purpose: Metastatic prostate cancer is incurable and a standard treatment is life-long, palliative, hormone therapy. Improving treatments for Veterans with metastatic prostate cancer is therefore an unmet need.
Background: The approach to metastatic prostate cancer is evolving in response to improvements in androgen suppressive therapies, demonstration that stereotactic body radiotherapy (SBRT) offers control of metastatic sites in excess of 95%, and improved imaging. Retrospective data from the West LA VA suggests Veterans with metastatic prostate cancer with 5 or fewer metastasis have improved outcomes as compared to those with > 5 metastases. This raises the question if a multimodal approach with aggressive, early treatment of newly diagnosed metastatic prostate cancer could be attempted with curative intent.
Methods: We will conduct a single arm phase 2 trial in 28 Veterans with newly diagnosed M1a,b prostate cancer and 1 to 5 radiographically visible metastases staged by NaF or PSMA PET-CT. Treatments include radical prostatectomy and adjuvant fractionated radiotherapy, metastasis directed SBRT, and complete ADT: leuprolide, abiraterone acetate, apalutamide for a total of six months systemic therapy. The primary endpoint is the percent of Veterans achieving a PSA < 0.05 ng/mL six months after recovery of testosterone to ≥ 150 ng/dL, a surrogate for disease control. Secondary endpoints include biochemical progression, radiographic progression, cancer specific survival, health-related quality of life. Prior to treatment, Veterans undergo a radiographic directed biopsy of a metastatic lesion to confirm metastatic disease and obtain metastatic tumor tissue for correlative genomic studies. Genomic analyses to investigate molecular correlates to lethal primary prostate tumors and the emergence of metastases will use the pretreatment tissue from directed biopsies of metastases and the radical prostatectomy specimens.
Conclusions: Accrual will proceed over five years at the VA West LA and Long Beach Medical Centers. It is anticipated that determination of the primary endpoint for each patient will take place within 18 months of his initiation of therapy.
Implications: The treatment approach to Veterans with oligometastatic prostate cancer could pivot from palliation toward cure. The correlative analyses could identify genomic features of potentially lethal primary tumors and may elucidate the proximal mechanistic drivers of metastasis.
Purpose: Metastatic prostate cancer is incurable and a standard treatment is life-long, palliative, hormone therapy. Improving treatments for Veterans with metastatic prostate cancer is therefore an unmet need.
Background: The approach to metastatic prostate cancer is evolving in response to improvements in androgen suppressive therapies, demonstration that stereotactic body radiotherapy (SBRT) offers control of metastatic sites in excess of 95%, and improved imaging. Retrospective data from the West LA VA suggests Veterans with metastatic prostate cancer with 5 or fewer metastasis have improved outcomes as compared to those with > 5 metastases. This raises the question if a multimodal approach with aggressive, early treatment of newly diagnosed metastatic prostate cancer could be attempted with curative intent.
Methods: We will conduct a single arm phase 2 trial in 28 Veterans with newly diagnosed M1a,b prostate cancer and 1 to 5 radiographically visible metastases staged by NaF or PSMA PET-CT. Treatments include radical prostatectomy and adjuvant fractionated radiotherapy, metastasis directed SBRT, and complete ADT: leuprolide, abiraterone acetate, apalutamide for a total of six months systemic therapy. The primary endpoint is the percent of Veterans achieving a PSA < 0.05 ng/mL six months after recovery of testosterone to ≥ 150 ng/dL, a surrogate for disease control. Secondary endpoints include biochemical progression, radiographic progression, cancer specific survival, health-related quality of life. Prior to treatment, Veterans undergo a radiographic directed biopsy of a metastatic lesion to confirm metastatic disease and obtain metastatic tumor tissue for correlative genomic studies. Genomic analyses to investigate molecular correlates to lethal primary prostate tumors and the emergence of metastases will use the pretreatment tissue from directed biopsies of metastases and the radical prostatectomy specimens.
Conclusions: Accrual will proceed over five years at the VA West LA and Long Beach Medical Centers. It is anticipated that determination of the primary endpoint for each patient will take place within 18 months of his initiation of therapy.
Implications: The treatment approach to Veterans with oligometastatic prostate cancer could pivot from palliation toward cure. The correlative analyses could identify genomic features of potentially lethal primary tumors and may elucidate the proximal mechanistic drivers of metastasis.
Post-Treatment Follow-Up by Oncologic Specialists as a Relevant Component of Cancer Survivorship for Veteran Patients Living in Rural Area
Purpose: To present a lesson learned from a pilot project aiming to improve post-radiotherapy (RT) followup (FU) care for Veterans living in rural area within our VISN, thereby questioning if FU care as dictated by oncologic specialists would be beneficial in a rural Veteran’s cancer survivorship.
Methods: A team of radiation oncology (RO) specialists was assembled to include clinical providers and medical physicists. A 2-pronged approach was employed: 1 by inperson visit at selected rural community-based outpatient clinic (rCBOC), the other via telehealth link. Target population included rural Veterans who had received RT at either a VA or Non-VA Care Center (NVCC) facility. On-site visits were done by RO specialists at each rCBOC. Patient satisfaction was evaluated via feedback survey. Mileage and time saved were calculated for each Veteran who might otherwise travel to see a VA RO specialist.
Results: In a span of 14 months, 9 separate rCBOC visits were made for 3 sites and a total of 49 Veteran visits. Excellent patient satisfaction was obtained, and the average mileage and time saved per Veteran visit was 217.2 miles and 201 min (off-traffic peak), respectively. However, 4 of 5 NVCC treatment plans encountered contained physics quality assurance (QA) data not considered to have met professional standards. Dedicated telehealth equipment was acquired and connections validated. Challenges faced included: soliciting timely assistance of administrative leadership, identifying patients to be seen and accessing their records, and obtaining clinical privilege and EHR access at rCBOCs.
Implications: Access to post-treatment cancer care for rural Veterans can be improved with in-person visits by VA oncologic specialists at corresponding rCBOCs. Barriers due to distance and time can be reduced significantly, with excellent patient satisfaction outcome. The efficacy of telehealth link requires further clinical testing. Furthermore, the inadvertent finding of physics QA deficiencies at NVCC sites raised plausible concern for overall quality of RT care, reflecting the probable need for future oversight by VA specialists. By reaching out to rural Veterans proactively, VA oncologic specialists can enhance their post-treatment cancer care, thereby improving their cancer survivorship.
Purpose: To present a lesson learned from a pilot project aiming to improve post-radiotherapy (RT) followup (FU) care for Veterans living in rural area within our VISN, thereby questioning if FU care as dictated by oncologic specialists would be beneficial in a rural Veteran’s cancer survivorship.
Methods: A team of radiation oncology (RO) specialists was assembled to include clinical providers and medical physicists. A 2-pronged approach was employed: 1 by inperson visit at selected rural community-based outpatient clinic (rCBOC), the other via telehealth link. Target population included rural Veterans who had received RT at either a VA or Non-VA Care Center (NVCC) facility. On-site visits were done by RO specialists at each rCBOC. Patient satisfaction was evaluated via feedback survey. Mileage and time saved were calculated for each Veteran who might otherwise travel to see a VA RO specialist.
Results: In a span of 14 months, 9 separate rCBOC visits were made for 3 sites and a total of 49 Veteran visits. Excellent patient satisfaction was obtained, and the average mileage and time saved per Veteran visit was 217.2 miles and 201 min (off-traffic peak), respectively. However, 4 of 5 NVCC treatment plans encountered contained physics quality assurance (QA) data not considered to have met professional standards. Dedicated telehealth equipment was acquired and connections validated. Challenges faced included: soliciting timely assistance of administrative leadership, identifying patients to be seen and accessing their records, and obtaining clinical privilege and EHR access at rCBOCs.
Implications: Access to post-treatment cancer care for rural Veterans can be improved with in-person visits by VA oncologic specialists at corresponding rCBOCs. Barriers due to distance and time can be reduced significantly, with excellent patient satisfaction outcome. The efficacy of telehealth link requires further clinical testing. Furthermore, the inadvertent finding of physics QA deficiencies at NVCC sites raised plausible concern for overall quality of RT care, reflecting the probable need for future oversight by VA specialists. By reaching out to rural Veterans proactively, VA oncologic specialists can enhance their post-treatment cancer care, thereby improving their cancer survivorship.
Purpose: To present a lesson learned from a pilot project aiming to improve post-radiotherapy (RT) followup (FU) care for Veterans living in rural area within our VISN, thereby questioning if FU care as dictated by oncologic specialists would be beneficial in a rural Veteran’s cancer survivorship.
Methods: A team of radiation oncology (RO) specialists was assembled to include clinical providers and medical physicists. A 2-pronged approach was employed: 1 by inperson visit at selected rural community-based outpatient clinic (rCBOC), the other via telehealth link. Target population included rural Veterans who had received RT at either a VA or Non-VA Care Center (NVCC) facility. On-site visits were done by RO specialists at each rCBOC. Patient satisfaction was evaluated via feedback survey. Mileage and time saved were calculated for each Veteran who might otherwise travel to see a VA RO specialist.
Results: In a span of 14 months, 9 separate rCBOC visits were made for 3 sites and a total of 49 Veteran visits. Excellent patient satisfaction was obtained, and the average mileage and time saved per Veteran visit was 217.2 miles and 201 min (off-traffic peak), respectively. However, 4 of 5 NVCC treatment plans encountered contained physics quality assurance (QA) data not considered to have met professional standards. Dedicated telehealth equipment was acquired and connections validated. Challenges faced included: soliciting timely assistance of administrative leadership, identifying patients to be seen and accessing their records, and obtaining clinical privilege and EHR access at rCBOCs.
Implications: Access to post-treatment cancer care for rural Veterans can be improved with in-person visits by VA oncologic specialists at corresponding rCBOCs. Barriers due to distance and time can be reduced significantly, with excellent patient satisfaction outcome. The efficacy of telehealth link requires further clinical testing. Furthermore, the inadvertent finding of physics QA deficiencies at NVCC sites raised plausible concern for overall quality of RT care, reflecting the probable need for future oversight by VA specialists. By reaching out to rural Veterans proactively, VA oncologic specialists can enhance their post-treatment cancer care, thereby improving their cancer survivorship.
How Can VA Optimize Palliative Oncology Care? The AVAHO Palliative Care Research Subcommittee Is Laying the Groundwork for Productive Collaboration
Purpose: Palliative Care is essential to Oncology. The purpose of this abstract is to describe the AVAHO Palliative Care Research subcommittee, its objectives, and evidence of its productive multi-disciplinary and inter-institutional collaboration.
Background: The American Society of Clinical Oncology (ASCO) recommends Palliative Care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. VA mandates Palliative Care inpatient consult teams for all medical facilities. It is not clearly known how Palliative Care is integrated into standard VA outpatient Oncology practice. In addition, questions remain regarding the optimal way(s) to provide Palliative Oncology Care. The AVAHO Palliative Care Research subcommittee was established in 2015 and currently has 7 members from 7 VA institutions. The mission of the subcommittee is to develop partnerships among VA clinicians, pharmacists, social workers, researchers, and VA leadership with the shared goal of providing optimal Palliative Oncology Care within the VA. In laying the groundwork for productive collaboration, we have identified a need to better understand the current interface between VA Oncology Clinics and Palliative Care teams. In particular, we seek to review the evidence for providing on-site Palliative Care to patients with advanced malignancies, and we seek to understand the current availability of outpatient Palliative Care within VA outpatient Oncology clinics.
Methods: We have identified 2 initial approaches to address these questions. First, we have submitted a proposal to the VA Evidence-Based Synthesis Program (ESP) to review the evidence regarding optimal Palliative Care delivery methods for patients with advanced malignancies and
the feasibility of providing on-site Palliative Care embedded into VA Oncology clinics. Second, we plan to survey current VA Oncology providers to understand their Palliative Care referral patterns, available on-site resources, and barriers to providing optimal Palliative Care for their patients.
Analysis/Results: At the AVAHO 2016 meeting, we will provide updated information on the ESP proposal and the Palliative Care in Oncology Survey.
Conclusion: The AVAHO Palliative Care Research subcommittee represents a multidisciplinary and inter-institutional collaboration with a common goal of optimizing VA Palliative Oncology Care. This subcommittee is a model of how AVAHO can foster productive collaborations. We welcome new members.
Purpose: Palliative Care is essential to Oncology. The purpose of this abstract is to describe the AVAHO Palliative Care Research subcommittee, its objectives, and evidence of its productive multi-disciplinary and inter-institutional collaboration.
Background: The American Society of Clinical Oncology (ASCO) recommends Palliative Care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. VA mandates Palliative Care inpatient consult teams for all medical facilities. It is not clearly known how Palliative Care is integrated into standard VA outpatient Oncology practice. In addition, questions remain regarding the optimal way(s) to provide Palliative Oncology Care. The AVAHO Palliative Care Research subcommittee was established in 2015 and currently has 7 members from 7 VA institutions. The mission of the subcommittee is to develop partnerships among VA clinicians, pharmacists, social workers, researchers, and VA leadership with the shared goal of providing optimal Palliative Oncology Care within the VA. In laying the groundwork for productive collaboration, we have identified a need to better understand the current interface between VA Oncology Clinics and Palliative Care teams. In particular, we seek to review the evidence for providing on-site Palliative Care to patients with advanced malignancies, and we seek to understand the current availability of outpatient Palliative Care within VA outpatient Oncology clinics.
Methods: We have identified 2 initial approaches to address these questions. First, we have submitted a proposal to the VA Evidence-Based Synthesis Program (ESP) to review the evidence regarding optimal Palliative Care delivery methods for patients with advanced malignancies and
the feasibility of providing on-site Palliative Care embedded into VA Oncology clinics. Second, we plan to survey current VA Oncology providers to understand their Palliative Care referral patterns, available on-site resources, and barriers to providing optimal Palliative Care for their patients.
Analysis/Results: At the AVAHO 2016 meeting, we will provide updated information on the ESP proposal and the Palliative Care in Oncology Survey.
Conclusion: The AVAHO Palliative Care Research subcommittee represents a multidisciplinary and inter-institutional collaboration with a common goal of optimizing VA Palliative Oncology Care. This subcommittee is a model of how AVAHO can foster productive collaborations. We welcome new members.
Purpose: Palliative Care is essential to Oncology. The purpose of this abstract is to describe the AVAHO Palliative Care Research subcommittee, its objectives, and evidence of its productive multi-disciplinary and inter-institutional collaboration.
Background: The American Society of Clinical Oncology (ASCO) recommends Palliative Care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. VA mandates Palliative Care inpatient consult teams for all medical facilities. It is not clearly known how Palliative Care is integrated into standard VA outpatient Oncology practice. In addition, questions remain regarding the optimal way(s) to provide Palliative Oncology Care. The AVAHO Palliative Care Research subcommittee was established in 2015 and currently has 7 members from 7 VA institutions. The mission of the subcommittee is to develop partnerships among VA clinicians, pharmacists, social workers, researchers, and VA leadership with the shared goal of providing optimal Palliative Oncology Care within the VA. In laying the groundwork for productive collaboration, we have identified a need to better understand the current interface between VA Oncology Clinics and Palliative Care teams. In particular, we seek to review the evidence for providing on-site Palliative Care to patients with advanced malignancies, and we seek to understand the current availability of outpatient Palliative Care within VA outpatient Oncology clinics.
Methods: We have identified 2 initial approaches to address these questions. First, we have submitted a proposal to the VA Evidence-Based Synthesis Program (ESP) to review the evidence regarding optimal Palliative Care delivery methods for patients with advanced malignancies and
the feasibility of providing on-site Palliative Care embedded into VA Oncology clinics. Second, we plan to survey current VA Oncology providers to understand their Palliative Care referral patterns, available on-site resources, and barriers to providing optimal Palliative Care for their patients.
Analysis/Results: At the AVAHO 2016 meeting, we will provide updated information on the ESP proposal and the Palliative Care in Oncology Survey.
Conclusion: The AVAHO Palliative Care Research subcommittee represents a multidisciplinary and inter-institutional collaboration with a common goal of optimizing VA Palliative Oncology Care. This subcommittee is a model of how AVAHO can foster productive collaborations. We welcome new members.